| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
Guest Access | Sign In via User Name/Password
|
|
|
|||||||
Guest Access | Sign In via User Name/Password |
|||||||||
Jackson, MS
Dr. Baumann is Professor of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Mississippi Medical Center.
Correspondence to: Michael H. Baumann, MD, MS, FCCP, Professor of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Mississippi Medical Center, 2500 North State St, Jackson, MS 39216-4505; e-mail: mbaumann{at}medicine.umsmed.edu
Despite recent predictions of impending death for closed pleural biopsy,1 Chakrabarti and colleagues (see page 1549)2 provide convincing evidence that pleural biopsy still has a pulse. The authors’ data and discussion offer several points worth reinforcing. In the setting of a diagnostically negative thoracentesis with findings consistent with an exudative effusion, closed pleural biopsy provides a 51% diagnostic sensitivity for pleural malignancy when pleural tissue is successfully obtained. This success was not directly proportional to the level of training, as has been found by others.3 A trend supporting more biopsies increasing the yield for pleural malignancy was noted; the lack of statistical significance likely represents a ß error. Earlier studies of tuberculous pleuritis4 and pleural malignancy5 have shown that more closed pleural biopsy specimens increase the diagnostic yield. The current study reconfirms the limited morbidity of pleural biopsy.
In addition to the retrospective nature of the study, other limitations exist. Included in these limits are a lack of malignancy staging, which might have correlated with diagnostic sensitivity, and no pleural fluid values reported other than for protein. Suspicion of pleural tuberculosis remains the most compelling indication for closed pleural biopsy.4 Combined pleural fluid and biopsy studies establish the diagnosis of tuberculous pleuritis in up to 95% of cases compared to the generally lower yields for pleural malignancy (73%).4 The yield for pleural tuberculosis from combined pleural fluid and closed pleural biopsy does not differ from that obtained by thoracoscopy.4 Due to the low prevalence of tuberculous pleurisy in the patient population of the study by Chakrabarti and colleagues,2 tuberculosis was not found by pleural biopsy in any of their patients.
These and other study limitations minimally detract from the findings outlined above. More compelling to consider is the fact that yet another study on closed pleural biopsy was submitted for publication. Why do clinicians persist in performing closed pleural biopsy and exert the effort reporting their findings from a procedure supposedly in its death throes? Several observations pertain. A mastery of pleural biopsy requires limited experience. Baseline proficiency in thoracentesis and performance of an initial five supervised biopsy procedures, followed by the performance of five biopsy procedures per year, are suggested as being adequate for competency.6 Compare this to the initial performance of 20 supervised procedures that is suggested for competency in medical thoracoscopy (pleuroscopy), and the substantially greater capital equipment costs and larger procedure support team required for thoracoscopy.6 In the United Kingdom, "nonspecialist trainees" (equivalent of interns and residents in the United States)2 and "nonspecialist graduates"3 successfully and safely obtain pleural tissue, confirming the limited experience required to accomplish pleural biopsy.
Such ready accessibility by a spectrum of clinicians encourages the continued use of pleural biopsy, particularly where the availability of more expensive and technically challenging thoracoscopy is limited. Silvestri and Strange1 contend that "some countries will continue to keep needle pleural biopsy in their algorithm for undiagnosed pleural effusions because of a belief in its use or cost constraints associated with pleuroscopy." The United States, especially when considering rural and cash strapped urban areas, should remain one of those countries. This should be true particularly when pleural tuberculosis is the primary concern.
Clinicians from areas with higher incidences of pleural tuberculosis, such as Spain,57 continue to use pleural biopsy despite publications highlighting alternate pleural fluid studies, notably, those for adenosine deaminase.148 In the United States, a tuberculosis culture and susceptibility testing remain a mainstay of the Centers for Disease Control and Prevention recommendations.9 In the United States, drug resistance patterns of pleural tuberculosis generally reflect those of pulmonary tuberculosis (see the study by Baumann et al10 and unpublished data), making the culture of the tuberculosis organism a must in certain subgroups including foreign-born patients.
With such advantages, why is closed pleural biopsy considered to be obsolete by some? Medical thoracoscopy is increasingly popular in the United States.1 Thoracoscopy clearly has higher diagnostic sensitivity for pleural malignancy than closed pleural biopsy alone or in combination with pleural fluid analysis. Thoracoscopy also facilitates the performance of pleurodesis to prevent effusion recurrence.4 As noted, no such clear diagnostic superiority of thoracoscopy over pleural biopsy exists for pleural tuberculosis.4 Chakrabarti et al2 acknowledge the higher yield of CT scan-guided pleural biopsy when compared to the Abrams closed pleural biopsy in patients with a malignancy. CT scan guidance and the skill required for image-directed pleural biopsy add cost and complexity, and, as with medical thoracoscopy, are not always available. Specificity and accessibility issues hamper positron emission tomography of the pleura in the diagnosis of pleural malignancy.11 Adding an ultrasound of the pleura to direct pleural biopsy, as Chakrabarti et al2 suggest, is not universally available and arguably adds an unnecessary cost. Given the high 6-month mortality rate (48%) in patients with pleural malignancy diagnosed thoracoscopically, and the frequently associated limited therapeutic options, conservative follow-up can be argued for in patients with suspected pleural malignancy with initially negative pleural fluid cytology findings and negative pleural biopsy findings.4
The Accreditation Council for Graduate Medical Education (ACGME) enhanced the taint of obsolescence by no longer requiring competence in performing pleural biopsy by pulmonary and critical care fellows in training.12 Less than 50% of surveyed trainees in fellowship programs (2002 or 2003 graduating class) achieved the suggested competency levels in performing closed pleural biopsy.13 Ninety-one percent of surveyed programs offered training in pleural biopsy, while only 12% offered training in medical thoracoscopy.13 The findings of a survey of pulmonary and/or critical care trainees or graduates at CHEST 2004 (unpublished data) reinforced the notion of a decline in the training in and use of closed pleural biopsy; of 131 respondents, only 56% had performed pleural biopsies.
The ACGME appears to have delivered this blow to the viability of pleural biopsy without considering the issue of accessibility to an effective alternative. Perhaps the ACGME should encourage intern and residency training in closed pleural biopsy given the current limited training of subspecialist trainees? Such training should reinforce the value of pleural biopsy primarily in patients with suspected pleural tuberculosis and in pleural malignancy in situations in which thoracoscopy is not readily available. In the meantime, prospective studies comparing efficacy and all of the pertinent costs of closed pleural biopsy vs thoracoscopy in the setting of pleural malignancy and tuberculosis are required. The option of conservative monitoring of patients who are suspected of pleural malignancy should be included in such studies.
Footnotes
Dr. Baumann has no conflicts of interest to disclose.
References
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
